Dorsal root entry zone lesions for conus medullaris root avulsions

We have found dorsal root entry zone (DREZ) lesions to be an effective treatment of chronic deafferentation pain in patients who have had avulsions of the dorsal rootlets from the spinal cord. Eight patients were operated in whom chronic pain of the lower extremity resulted from dorsal root avulsions from the conus medullaris. In 7 of the 8 patients, the mechanism of injury was a motor vehicle accident; all 7 sustained severe pelvic trauma. Seven of the 8 patients remained pain-free, off all narcotics, with an average follow-up of 33 months. All patients had DREZ lesions of the conus performed by radiofrequency techniques.     

Predictive value of computed tomographic myelography in obstetrical brachial plexus palsy

Preoperative radiologic studies to detect root avulsions of the brachial plexus caused by birth trauma are considered useful in assisting with surgical planning for reconstruction. In this study, the predictive value of computed tomographic (CT) myelography in detecting nerve root avulsions at our institution was determined. Sixty-three consecutive patients with an obstetrical brachial plexus palsy who had had both preoperative CT myelography and reconstructive surgery were selected. All CT myelograms were analyzed post hoc by a single neuroradiologist in a manner blind to the surgical findings. At each root level of the brachial plexus, the presence of a pseudomeningocele was noted along with the presence or absence of rootlets within each identified pseudomeningocele. Extraforaminal root avulsions later determined at surgery were reviewed by a single surgeon in a manner blind to the radiographic results. Surgical and radiographic findings were then compared at each corresponding root level. A total of 281 roots were examined. The sensitivity, specificity, positive predictive value, and likelihood ratio for root avulsions with pseudomeningoceles were 0.63, 0.85, 0.40, and 4.2, respectively. For pseudomeningoceles for which rootlets traversing the sac could not be identified, these values were 0.37, 0.98, 0.74, and 18.5, respectively. The presence of pseudomeningoceles with or without rootlets was not a sensitive indicator of root avulsions. Root avulsions were better predicted by identifying the absence of rootlets in a pseudomeningocele. This absence on CT myelography may be used to suggest an extraforaminal root avulsion due to its high specificity and high likelihood ratio.     

Patterns in ritual tooth avulsion at Roonka

Tooth avulsion is the intentional removal of one or more teeth for ritual or aesthetic reasons, or to denote group affiliation. Typically the maxillary incisors are the teeth most often selected for removal. Previous authors have discussed the presence of tooth avulsions in several individuals recovered from Roonka, but those papers did not examine any patterns in those removals that might be present. Analysis of the tooth avulsions at Roonka reveals a change in the practice over time, with the older burials from phase II typically showing removal of both maxillary central incisors with a left side bias when only one tooth is removed, and the more recent phase III burials showing only one incisor avulsed and a right side bias for removal. Frequencies in the practice also changed over time, with avulsions being much more common in the older phase II burials. Historical evidence suggests that any particular regional or social group would have its own particular pattern of tooth avulsion, so these changes in tooth avulsions at Roonka suggest that the site was either used by multiple groups of people for burials, or that there was significant cultural change during the occupation of the site. Am J Phys Anthropol 154:479–485, 2014. © 2014 Wiley Periodicals, Inc.     

Direct cord implantation in brachial plexus avulsions: revised technique using a single stage combined anterior (first) posterior (second) approach and end-to-side side-to-side grafting neurorrhaphy

Background

The superiority of a single stage combined anterior (first) posterior (second) approach and end-to-side side-to-side grafting neurorrhaphy in direct cord implantation was investigated as to providing adequate exposure to both the cervical cord and the brachial plexus, as to causing less tissue damage and as to being more extensible than current surgical approaches.

Methods

The front and back of the neck, the front and back of the chest up to the midline and the whole affected upper limb were sterilized while the patient was in the lateral position; the patient was next turned into the supine position, the plexus explored anteriorly and the grafts were placed; the patient was then turned again into the lateral position, and a posterior cervical laminectomy was done. The grafts were retrieved posteriorly and side grafted to the anterior cord. Using this approach, 5 patients suffering from complete traumatic brachial plexus palsy, 4 adults and 1 obstetric case were operated upon and followed up for 2 years. 2 were C5,6 ruptures and C7,8T1 avulsions. 3 were C5,6,7,8T1 avulsions. C5,6 ruptures were grafted and all avulsions were cord implanted.

Results

Surgery in complete avulsions led to Grade 4 improvement in shoulder abduction/flexion and elbow flexion. Cocontractions occurred between the lateral deltoid and biceps on active shoulder abduction. No cocontractions occurred after surgery in C5,6 ruptures and C7,8T1 avulsions, muscle power improvement extended into the forearm and hand; pain disappeared.

Limitations include

spontaneous recovery despite MRI appearance of avulsions, fallacies in determining intraoperative avulsions (wrong diagnosis, wrong level); small sample size; no controls rule out superiority of this technique versus other direct cord reimplantation techniques or other neurotization procedures; intra- and interobserver variability in testing muscle power and cocontractions.

Conclusion

Through providing proper exposure to the brachial plexus and to the cervical cord, the single stage combined anterior (first) and posterior (second) approach might stimulate brachial plexus surgeons to go more for direct cord implantation. In this study, it allowed for placing side grafts along an extensive donor recipient area by end-to-side, side-to-side grafting neurorrhaphy and thus improved results.

Level of evidence

Level IV, prospective case series.     

Common injuries of the athlete's hand.

Hand injuries are among the most frequent accidents seen in sports medicine. All too commonly they are considered trivial since the athlete may continue to participate actively and neglect his injury. The consequent delay in diagnosis and proper treatment may result in long-standing or even permanent disability. This paper describes the more commonly encountered hand injuries, their diagnosis and their optimal treatment. Included are soft-tissue injuries, ligamentous injuries, fractures and tendon avulsions. The basic principles applicable to skeletal and soft-tissue trauma of the hand, which physicians at all levels of sports medicine may encounter, are stressed.     

In lumbosacral plexus injuries can we identify indicators that predict spontaneous recovery or the need for surgical treatment? Results from a clinical study on 72 patients

Background

Post-traumatic lumbosacral plexus injuries seem to be rare events, spontaneously recovering in high percentage: as surgery is often challenging and results in poor outcome, many Authors have advocated conservative treatment only. Nevertheless surgery should not be ruled out: in invalidating injuries, it can restore basic function in the lower extremities. Therefore, it might be necessary to establish guidelines for the management and the indication to surgery in such cases. This study aims to identify indicators predicting spontaneous recovery or the need for surgery.

Method

The clinical and radiological data of 72 patients with a post-traumatic lumbosacral plexus injury were reviewed. A follow up equal or superior to 3 years is available in 42 cases.

Results

Lumbosacral plexus injuries mostly occurred during road accidents. The incidence of associated lesions was relevant: bone injuries were found in 85% of patients, internal lesions in 30% and vascular injuries in 8%. Lumbosacral trunk and sacral plexus palsies were the most frequent injury patterns. Root avulsions were revealed in 23% of cases and only in sacral plexus and complete lumbosacral plexus injuries: L5 and S1 were the roots more prone to avulsions. About 70% of cases recovered spontaneously, mostly in 18 months. Spontaneous recovery was the rule in lumbar plexus and lumbosacral trunk injuries (where root avulsions never occurred) or in sacral and complete lumbosacral plexus palsies due to compression injuries. The causative mechanism correlated with the injury pattern, the associated bone injury being often predictive of the severity of the nerve injury. Lumbosacral plexus injuries occurred in car crashes were generally associated with fractures causing compression on the nerves, thus resulting in injuries often amenable of spontaneous recovery. Motorcycle accidents implied high kinetic energy traumas where traction played an important role, as the high percentage of sacroiliac joint separations demonstrated (found in more than 50% of cases and always associated to root avulsions). Loss of sphincteral control and excruciating leg pain were also invariably associated with avulsions.

Conclusions

Clinical and radiological data can help to predict the occurrence of spontaneous recovery or the need for surgery in post-traumatic lumbosacral plexus injuries.     

Composite in situ vein bypass for upper extremity revascularization

Chronic upper extremity arterial insufficiency is rare. Consequently, major reports specifically limited to the topic are scarce, and the clinical experience is small. In addition, symptomatology, diagnostic criteria, and guidelines for surgical management remain ill-defined. In the lower extremities, however, in situ vein bypass has been attempted for nearly three decades. This technique offers many advantages over traditional revascularization methods. Although the procedure has become popular for the lower extremity, no report of its use in the upper extremity is found in the literature. We report what may be the first case in which in situ bypass was used in the upper extremity for a threatened limb secondary to diabetic occlusive vascular disease complicated by a previous shunt used for hemodialysis. Revascularization of the upper extremity using the in situ vein bypass technique may offer a new alternative to traditional methods of revascularization.     

Primary motor cortex reorganization in a long-term monkey amputee

The primary motor cortex (M1) was mapped with intracortical microstimulation (ICMS) in a 15 year-old macaque whose right upper extremity was amputated at the shoulder joint prior to 2 years of age. Movements of the right shoulder girdle and stump were evoked by ICMS throughout the left M1 upper extremity region. The size of the left M1 upper extremity region contralateral to the amputated arm was not appreciably different from the size of the right upper extremity region contralateral to the intact arm. Long stimulus trains and/or higher stimulus currents were needed to evoke detectable movements at significantly more loci in the left than in the right M1 upper extremity region. These observations would be consistent with unmasking of a high threshold representation of shoulder musculature that normally exists throughout the central core of the upper extremity region, where it underlies a lower threshold representation of the distal forelimb. Alternatively, invasion of the de-efferented distal forelimb core by surrounding shoulder representation may have occurred. Differences between the limited M1 reorganization observed in the present study and the more extensive reorganization of S1 observed in other studies may reflect fundamental differences between M1 and S1, and/or differences in the extent of de-efferentation versus deafferentation.     

Successful replantation of an amputated nasal tip by microvascular anastomosis

Successful microsurgical replantation of a completely avulsed nasal tip is presented. The result is excellent. The technical challenge involved no sizable veins for drainage. This problem was solved by an artery-to-vein shunting. For facial avulsions, there is nothing superior to the original tissue, and replantation should always be attempted first.     

Upper extremity sensorimotor control among collegiate football players

Injuries stemming from shoulder instability are very common among athletes participating in contact sports, such as football. Previous research has shown that increased laxity negatively affects the function of the sensorimotor system potentially leading to a pathological cycle of shoulder dysfunction. Currently, there are no data detailing such effects among football players. Therefore, the purpose of this study was to examine the differences in upper extremity sensorimotor control among football players compared with that of a control group. Forty-five collegiate football players and 70 male control subjects with no previous experience in contact sports participated. All the subjects had no recent history of upper extremity injury. Each subject performed three 30-second upper extremity balance trials on each arm. The balance trials were conducted in a single-arm push-up position with the test arm in the center of a force platform and the subjects' feet on a labile device. The trials were averaged, and the differences in radial area deviation between groups were analyzed using separate 1-way analyses of variance (p < 0.05). The football players showed significantly more radial area deviation of the dominant (0.41 ± 1.23 cm2, p = 0.02) and nondominant arms (0.47 ± 1.63 cm2, p = 0.03) when compared with the control group. These results suggest that football players may have decreased sensorimotor control of the upper extremity compared with individuals with no contact sport experience. The decreased upper extremity sensorimotor control among the football players may be because of the frequent impacts accumulated during football participation. Football players may benefit from exercises that target the sensorimotor system. These findings may also be beneficial in the evaluation and treatment of various upper extremity injuries among football players.     

Relationship between physiological energy expenditure and biomechanical patterns associated with erect standing

The deviation of the static weight-bearing patterns under the feet of a lower extremity handicapped person may be measured quantitatively in terms of the Static Weight-Bearing Index. This paper describes the correlation between this index and the physiological energy expenditure associated with the erect standing posture. The Static Weight-Bearing Index can be conveniently used for evaluation of the functional status of the human lower extremity system in stance in case of lower extremity disabled persons who maintain basic weight-bearing mode involving both the limbs in double support condition.     

Repairing the ventral root is sufficient for simultaneous motor and sensory recovery in multiple complete cervical root transection injuries

Aim

In multiple cervical root transection injuries, motor and sensory recovery has been demonstrated after repairing both dorsal and ventral roots with autologous grafts applied to the dorsal and ventral aspects, respectively. However, in clinical situations, autologous grafts may not be sufficient to repair both roots in this situation. In this study, the authors evaluated whether repairing ventral root alone is sufficient for simultaneous sensory and motor function recovery.

Main methods

In the transected group, the left 6th–8th cervical roots were pulled and transected at the spinal cord junction. In the repair group, the transected root was anastomosed to a single autologous nerve graft, which was inserted into the ventral horn through a pial incision. Acidic fibroblast growth factor mixed with fibrin glue was applied to the surgical area. Motor function, sensory function, cortical somatosensory evoked potentials (SSEPs), axon tracing, and CGRP⁺ fibers were evaluated.

Key findings

The repaired rats exhibited simultaneous sensory and motor function recovery. At the 16th weeks, SSEPs reappeared in all animals of the repair group, but not in the transected group. Retrograde axon tracing demonstrated an increased number of sensory neurons in the dorsal root ganglia and regenerating nerve fibers in the dorsal horn. CGRP⁺ fibers were significantly increased in the repair group and restricted to laminae I and II.

Significance

This is the first report that in multiple root avulsions with insufficient grafts, repairing ventral roots alone leads to both sensory recovery and motor recovery. This finding may help patients with multiple cervical root avulsions.     

Emergency free-flap transfer for reconstruction of acute complex extremity wounds.

Nine patients with complex extremity injuries were treated with emergency free-flap transfers over a 3 1/2-year period. The transferred emergency free flaps were performed to cover exposed vital structures. All flaps survived without infection. Complete and careful assessment of the systemic condition of the patient and the nature of the injured extremity is mandatory. Emergency free-flap transfers may salvage the limb or finger and may improve the functional and aesthetic results with the shortest possible hospital stay.     

The influence of altering push force effectiveness on upper extremity demand during wheelchair propulsion

Manual wheelchair propulsion has been linked to a high incidence of overuse injury and pain in the upper extremity, which may be caused by the high load requirements and low mechanical efficiency of the task. Previous studies have suggested that poor mechanical efficiency may be due to a low effective handrim force (i.e. applied force that is not directed tangential to the handrim). As a result, studies attempting to reduce upper extremity demand have used various measures of force effectiveness (e.g., fraction effective force, FEF) as a guide for modifying propulsion technique, developing rehabilitation programs and configuring wheelchairs. However, the relationship between FEF and upper extremity demand is not well understood. The purpose of this study was to use forward dynamics simulations of wheelchair propulsion to determine the influence of FEF on upper extremity demand by quantifying individual muscle stress, work and handrim force contributions at different values of FEF. Simulations maximizing and minimizing FEF resulted in higher average muscle stresses (23% and 112%) and total muscle work (28% and 71%) compared to a nominal FEF simulation. The maximal FEF simulation also shifted muscle use from muscles crossing the elbow to those at the shoulder (e.g., rotator cuff muscles), placing greater demand on shoulder muscles during propulsion. The optimal FEF value appears to represent a balance between increasing push force effectiveness to increase mechanical efficiency and minimize upper extremity demand. Thus, care should be taken in using force effectiveness as a metric to reduce upper extremity demand.     

Predicting asymmetrical lower extremity strength deficits in college-aged men and women using common horizontal and vertical power field tests: a possible screening mechanism

Strength deficits in the quadriceps and hamstrings have been linked to several lower extremity injuries. The most common protocol used in testing for these deficits is isokinetic strength testing, which is both costly and time consuming. Therefore, the purpose of this study was to employ common vertical and horizontal power field tests to identify those protocols that best predict lower extremity strength deficits. Data describing 22 healthy collegiate graduate students' vertical and horizontal power were collected using standard field tests (i.e., 2 feet vertical jump, single leg vertical jump, 40-, 50-, and 60-yd runs). In addition, data describing each subject's lower extremity strength deficits were collected by using the Biodex 840-000 Multi Joint System Isokinetic Dynamometer (Biodex Medical Systems, Shirley, NY, USA) set to report peak torque at 60° · s of flexion and extension and 180° · s of flexion and extension. Regression analyses indicated that 3 of the 4 strength deficit parameters could be predicted from a linear combination of field test results (p < 0.05). Of the strength deficits measured, hamstring deficits at flexion velocities of both 60° · s and quadriceps strength deficits at 60° · s were those that could be predicted using field test results. The results of this study, by increasing the diagnostic power of the clinician, may make it easier to develop strength training protocols designed specifically to target weak musculature in the lower extremity. This targeting of specific musculature, in an effort to return symmetrical strength to the lower extremity, may ultimately decrease the likelihood of lower extremity injury in college-aged men and women.     

Validity of median nerve somatosensory evoked potentials in the diagnosis of supraclavicular brachial plexus lesions

Experience with median nerve SEPs in the diagnosis of brachial plexus lesions is analysed in 49 patients selected from a total material of 264 cases with brachial plexus problems tested by SEP techniques. Median nerve SEPs were always compared with the results of SEPs after stimulation of at least one other nerve relevant to the site of the lesion as suspected clinically and electromyographically. All patients presented with unilateral brachial plexus problems and all root lesions were verified by clinical presentation, EMG studies, myelogram or surgery. There were 19 brachial plexus injuries, 13 cases with cervical spondylopathic rediculopaties without myelopathy and 7 patients presented brachial plexopathy with systemic cancer. It was found that median nerve SEPs were always normal in injuries of upper trunk and root avulsions confined to one or two root levels. Median nerve SEPs were abnormal in multiple trunk lesions and multiple root avulsions. In patients with spondylopathic radiculopathies median nerve SEPs were normal apart from one case where involvement of multiple roots was present. Median nerve SEPs were useful in assessing patients presenting brachial plexus problems in the presence of systematic cancer apart from cases where lower trunk involvement was present.In general, median nerve SEPs are useful if they are combined with SEP testing of other nerves anatomically more closely related to the problem as outlined clinically and electromyographically.     

Unplanned Excision of Extremity Soft Tissue Sarcoma in Korea: A Nationwide Study Based on a Claims Registry

Unplanned excision of extremity soft tissue sarcoma (STS) is common and has detrimental effects not only on patients’ oncologic outcomes but also on functional and economic issues. However, no study has analyzed a nationwide population-based database. To estimate the incidence and treatment pattern of unplanned excision in extremity STS in the Korean population, a nationwide epidemiologic study was performed using the Korean Health Insurance Review and Assessment Service database, a centralized nationwide healthcare claims registry of Korea that covers the entire Korean population. Among 1,517 patients with extremity STS in the 4-year study period, 553 (36.5%) underwent unplanned excision (unplanned group). About 80% of unplanned excisions were performed in tertiary or general hospitals. Of the unplanned group, 240 (43.4%) underwent re-excision with or without radiation therapy and/or chemotherapy, and 51 (9.2%) did not undergo re-excision but were treated with radiation therapy and/or chemotherapy; whereas, 262 (47.4%) did not undergo any further treatment following unplanned excision. This study is the first nationwide population-based study on the unplanned excision of extremity STS. The results may have implications in establishing preventive or therapeutic measures to reduce the burden of unplanned excision of extremity STS.     

Some considerations on the structure of quadruped extremities

An attempt is made to develop a general theory of the structure of an extremity of a quadruped or biped, based on its mechanical function. The problem is essentially one of dynamics of a chain of linked levers. The equations of motions of such systems are practically insoluble exactly at the present time. A very crude approximation method is therefore outlined. It is shown that, theoretically, the number of links in the chain forming the extremity may be determined by the optimum use of the total available force of the flexors and extensors. Discussion of the formula derived from this point of view shows, however, that actually this is not the determining factor. Other theoretical possibilities are discussed. While no application can be made at present, yet in principle it is shown how mechanical consideration can throw light on the anatomical structure of the extremity.     

Limb venous compliance in patients with idiopathic orthostatic intolerance and postural tachycardia.

Venous denervation and increased venous pooling may contribute to symptoms of orthostatic intolerance. We examined venous compliance in the calf and forearm in 11 orthostatic-intolerant patients and 15 age-matched controls over a range of pressures, during basal conditions and sympathetic excitation. Occlusion cuffs placed around the upper arm and thigh were inflated to 60 mmHg and deflated to 10 mmHg over 1 min. Limb volume was measured continuously with a mercury-in-Silastic strain gauge. Compliance was calculated as the numerical derivative of the pressure-volume curve. The pressure-volume relationship in the upper and lower extremities in the basal and sympathetically activated state was significantly lower in the orthostatic-intolerant patients (all P < 0.05). Sympathoexcitation lowered the pressure-volume relationship in the lower extremity in patients (P < 0.001) and controls (P < 0.01). Venous compliance was significantly less in patients in the lower extremity in the basal state over a range of pressures (P < 0.05). Venous compliance was less in patients compared with controls in the upper (P < 0.005) and lower extremities (P < 0.01) in the sympathetically activated state, but there were no differences at individual pressure levels. Sympathetic activation did not change venous compliance in the upper and lower extremity in patients and controls. Patients with orthostatic intolerance have reduced venous compliance in the lower extremity. Reduced compliance may limit the dynamic response to orthostatic change and thereby contribute to symptoms of orthostatic intolerance in this population group.     

Orthoses posted in both the forefoot and rearfoot reduce moments and angular impulses on lower extremity joints during walking

The purpose of the present study was to determine the effects of orthoses designed to support the forefoot and rearfoot on the kinematics and kinetics of the lower extremity joints during walking. Fifteen participants volunteered for this study. Kinematic and kinetic variables during overground walking were compared with the participants wearing sandals without orthoses or sandals with orthoses. Orthoses increased knee internal abduction moment during late stance and knee abduction angular impulse, and reduced the medial ground reaction force during late stance, adduction free moment, forefoot eversion angle, ankle inversion moment and angular impulse, hip adduction angle, hip abduction moment, and hip external rotation moment and angular impulse (p<0.05). Orthoses decreased the torsional forces on the lower extremity and reduced the loading at the hip during walking. These findings combined with our previous studies and those of others suggest that forefoot abnormalities are critically important in influencing lower extremity kinematics and kinetics, and may underlie some non-traumatic lower extremity injuries.